- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.26 / $1,802.26 / $4,634.37
| Facility | | $1,802.26 | $1,802.26 | $4,634.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.26 / $1,802.26 / $2,420.17
| Professional | | $1,802.26 | $1,802.26 | $2,420.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,875.50 / $5,187.92 / $5,792.96
| Professional | | $3,875.50 | $5,187.92 | $5,792.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.32 / $2,958.32 / $4,342.95
| Professional | | $2,958.32 | $2,958.32 | $4,342.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.79 / $1,956.73 / $4,634.37
| Facility | | $1,544.79 | $1,956.73 | $4,634.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.07 / $3,089.58 / $5,149.30
| Professional | | $1,313.07 | $3,089.58 | $5,149.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.34 / $2,626.14 / $4,376.91
| Professional | | $1,081.34 | $2,626.14 | $4,376.91 |